Summary: We will not investigate Mrs X’s complaint about the Council’s commissioned care for her late mother Mrs Y and how it considered her complaint. Investigation would not add to the Council’s investigation or achieve a different outcome. We cannot achieve the outcomes Mrs X seeks. We do not investigate councils’ complaint handling where we are not investigating the core issues giving rise to the complaint.

The complaint

1. Mrs X is the daughter of the late Mrs Y. Mrs Y was in a care home placement commissioned by the Council. Mrs X complains:
1. the care home failed to accept responsibility for the decline in Mrs Y’s health in the weeks before her death;
2. care home staff delayed in calling an ambulance for Mrs Y after she had fallen and broken her hip;
3. the care home failed to tell the family about that fall;
4. the Council failed to properly consider her complaint.
2. Mrs X says Mrs Y’s condition went downhill significantly after the first couple of weeks in the home: Mrs Y lost weight, was depressed and had three falls, the third one breaking her hip. Mrs Y went to hospital, had surgery, was discharged to a nursing home but died three weeks later. Mrs X says the family has been caused upset from not being told about Mrs Y’s fall and other care issues. She wants an apology to the family from the care home, and an inspection of the home by the Council or the Care Quality Commission (CQC).

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The Ombudsman’s role and powers

3. The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

• we could not add to any previous investigation by the organisation; or
• further investigation would not lead to a different outcome; or
• we cannot achieve the outcome someone wants.

(Local Government Act 1974, section 24A(6))

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How I considered this complaint

4. I considered information from Mrs X, the Care Quality Commission (CQC) fundamental care standards and the Ombudsman’s Assessment Code.

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My assessment

5. Mrs X considers Mrs Y’s care at the home caused a deterioration in her health, and she died a few weeks after her stay there. Her complaint refers to an inquest into Mrs Y’s death. It appears this was a coroner’s inquest rather than a safeguarding or other investigation not done by a coroner, because Mrs X reports witnesses being under oath. Whichever is the case, we cannot determine the care provided at the home contributed to or caused Mrs Y’s death. That would be a finding only a coroner could make. If there was a coroner’s inquest and Mrs X disagrees with its outcome, she would need to pursue that with the coroner.
6. The Council responded to Mrs X’s complaint after consultation with the care home. Officers determined there had been fault in some of the care home’s actions relating to Mrs Y’s care. They accepted staff should have called 999 instead of 111 after Mrs Y’s unwitnessed third fall. The home apologised for a member of staff who was rude to and upset Mrs Y’s granddaughter, and for not cleaning Mrs Y’s room after she had gone to hospital. Officers did not uphold or determined they could not make findings on other issues.
7. There was injustice caused to Mrs X by the Council-commissioned care home’s actions. But we cannot remedy injustice to Mrs Y by investigating now she has died. We do not investigate where investigation will not resolve the core injustice caused by the body in jurisdiction because a person has died. Mrs X and her family would have been understandably distressed by the matters they have raised relating to Mrs Y’s placement. But the Council has apologised for incidents which involved fault and passed on apologies from the care home for those matters, which is the appropriate outcome. The Council has set out what the care home will do to avoid staff calling 111 instead of 999 in future when an unwitnessed fall has happened. The care home has reminded staff of the process it already had in place, for them to call 999 where someone has had such a fall. There are no different outcomes an investigation would achieve here.
8. Mrs X is seeking a further apology directly from the care home. We do not investigate to achieve apologies, or further apologies. In any event, the body within our jurisdiction here is the Council, not the care provider, because it commissioned Mrs Y’s care from the home. We cannot make recommendations to a body which is not the one within our jurisdiction on a complaint. We could not make a recommendation to the care provider for it to apologise to Mrs Y’s family so cannot achieve this requested remedy.
9. Mrs X has sought an investigation of the care home by the Council or the CQC. We cannot order the Council or the CQC to initiate an investigation. As a care commissioner, it is for the Council to assess the suitability of the homes and services it commissions to provide assessed care needs. Mrs X’s complaint would be part of that ongoing process. We will share this decision statement with the CQC. But it remains for the CQC to determine if its fundamental care standards have been breached and how this information may inform future assessments of the care home.
10. Mrs X says the Council did not properly deal with her complaint. We do not investigate councils’ internal complaint handling processes in isolation where we are not investigating the core issues giving rise to the complaint. It is not a good use of our resources to do so. That limitation applies here so we will not investigate this part of the complaint.

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Final decision

11. We will not investigate Mrs X’s complaint because:
• investigation would not add to the Council’s consideration of the matters raised and would not achieve a different outcome; and
• we cannot achieve the outcomes Mrs X seeks; and
• we do not investigate councils’ complaint handling where we are not investigating the core issues giving rise to the complaint.

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Investigator's decision on behalf of the Ombudsman